ASHM Report Back

Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.

Dr Adam Bourne from La Trobe University in Melbourne spoke to four statements about safe sex drawn from his experience working in many countries.

1. Sex is safe if it feels safe

In some countries e.g. the Netherlands, HIV is being transmitted within regular sexual relationships rather than casual sex due to beliefs around the person being a risk rather than the type of sex being had. Familiarity, trust and a romantic halo effect led to more unsafe sex whereas perceptions about a person led to safe or no sex at all - e.g. in the U.K., 70% of men are not willing to have sex with a positive person.

2. Safe sex is what is possible

A world map of countries providing PrEP highlighted how PrEP is not an option in much of the world for safe sex. In some countries there is poor access to viral load testing making it not a tool for decision making. In some African countries water based lube is not available and it gets confiscated at customs due to association with gay sex.

3. Safe sex is about safe environments

Safe sex is non-threatening. What does safe sex mean when there is lack of consent or threats to physical safety? Nearly one in 5 MSM in Southern Africa have experienced blackmail, entrapment or rape. What about safe sex when under the influence of drugs or alcohol?

4. Safe sex is what I understand or appreciate

For many condoms still equals safe sex. For example in the UK only 30% of people have heard of PrEP and only 50% would use it if it was available. Other questions included can a pill really protect against HIV? Or what does undetectable mean?

Dr Bourne commented that Australia is ahead of many countries in Europe and UK with MSM knowledge about PrEP and also knowledge about safe sex within relationships i.e. talk test trust together.

In the plenary session on Wednesday morning, I was able to see Prof. Andrew Grulich from the Kirby Institute present information about maximising the population-level impact of PrEP. Initially he spoke about where we have come with PrEP from 2010 with the results from iPrEx study released through to 2012 US FDA approval, 2015 results from Ipergay and Proud studies and 2016 TGA approval in Australia. The PROUD and Ipergay studies show 86% efficacy in adherent individuals, research shows that adherence issues when measured in rectums is more forgiving than in vaginal mucosa where daily adherence to PrEP is more important - but notes no studies have been done in women.

PrEP Activism has highlighted what an important individual and population based intervention PrEP is, and education, demand building and advocacy for widespread availability has lead to @70% uptake in eligible high risk men in NSW and similarly in San Francisco. San Francisco has reported a 50% decrease in new diagnoses (not incidence).

Challenges continue to be in equitable access to PrEP, and identified young people and ethic minority groups being not well represented in PrEP uptake cohorts.

Increases in STIs are counterbalanced by increased testing and shorter duration of infection.

This talk inspires me to get back to work and recruit more clients to the QPrEPtrial in Brisbane.

The speakers presented a range of sessions around PrEP uptake and use in Gay and MSM.

Most use has been in the well connected, educated, white clients. Why are some gay and bisexual men eligible for PrEP but not taking it suggested that many see others at more risk than themselves. The flux cohort research suggested that there is increasing use of Meth and Viagra, adding Truvada into the mix for HIV protection, MTV.

Other risk reduction strategies include serosorting, strategic positioning and negotiating safety. A lot of PrEP users have decreased or stopped using condoms but there is an increasing awareness of the importance of undetectable viral loads. The final session discussed the lack of Indigenous health promotion material and lack of uptake/knowledge of, in this priority group.

If they were using it was probably in those "well integrated with the main stream MSM communities". Big positives for prep were that it is promoting disclosure and discussion with the Gay MSM community.

Dr Anna McNulty is the Conjoint Associate Professor for the School of Public Health and Community Medicine, the University of NSW as well as the Director of Sydney Sexual Health Centre and NSW Sexual Health Info link.

DR A. McNulty spoke about the HIV Dried Spot test which is an internet-based self -sampling test. Participants actually test themselves. The beauty of this test is that it increases access to HIV testing and fits in well with NSW HIV 96Normal 0 false false false EN-GB X-NONE X-NONE elimination Strategy for 2016-2020.The strategy targets the Men having sex with Men and culturally and linguistically diverse background as high priority populations.They are difficult to come forward

The spot test is advertised on print, digital and print media, especially on dating websites. Participants then register on line and their kits are sent via the post. The instructions are simple and an additional lancet is added in case the first one is spoiled. The participants will send back the kit to the laboratory where the test is done. The results are provided by a nurse via the phone or SMS.

Those that are positive are linked to care.

The Self-collecting method attracted people who have never tested before or those who rarely tested to test in the comfort of their own homes. The young, gay and homosexually active men are in this bracket. it was noted that there was an increase in access to CALD participants especially women.

The disadvantage of this method is that sexual behaviours will be under-reported.

This afternoon we had an opportunity to listen to Ms. Barbara Telfer, an Epidemiologist for HIV support program Health protection in NSW.

She spoke passionately about NSW goals to Virtually eliminate HIV transmission by 2020. Increase in HIV testing, diagnosis and early treatment irrespective of the CD4 count are the tools used to drive this goal home.The aim is to start treatment at least six months of diagnosis, follow them up to ascertain initiation of ART, retention in care and monitoring of CD4 count and viral load.

The surveillance started in 2013 and is ongoing and information required from participants was the year of diagnosis, demographics, language spoken at home, risk exposure, past testing history, cd4 count, and HIV viral load at diagnosis.

Statistics between 2013-2015 showed a general increase in HIV early ART initiation which is a positive change in clinical practice. The results were not impressive enough that there is need to reduce time to ART and increase early ART to the newly diagnosed especially CALD and residence in metro Sydney. Participants with a high CD4 count and or low Viral load or those lost in follow up post-diagnosis were top of the priority list.

It will be good to achieve this goal by 2020, were HIV infection will be a thing of the past.